Fracture

Introduction

• Break in the structural continuity of a bone• If the overlying skin remains intact - closed

(simple fracture)• If skin or one of the body cavities is breached-

open (compound fracture)

Types of Fracture

• Divided in to– Complete – Incomplete

Complete fracture

Bone is split into two or more fragments. Thefracture pattern on x-ray can help predict behaviourafter reduction• in a transverse fracture the fragments usually remain in

place after reduction• if it is oblique or spiral, they tend to shorten and re-displace

even if the bone is splinted. • In an impacted fracture the fragments are jammed tightly

together and the fracture line is indistinct. • A comminuted fracture is one in which there are more than

two fragments

Complete fractures: (a) transverse; (b) segmental and (c) spiral

Incomplete fracture

• The bone is incompletely divided and the periosteum remains in continuity

• Greenstick fracture : bone is buckled or bent– Mainly seen in children, because of their springy

bones– Plastically deformed bones

• Compressed fracture: crumpled cancellous bone– Seen in adults, mainly in vertebral bodies,

calcaneum and tibial plateu

Incomplete fractures:(a) buckle or torus and (b,c)) greenstick.

Muller’s Classification

(a) Each long bone has threesegments – proximalDiaphyseal Distalthe proximal and distal segments are each defined by a square based onthe widest part of the bone. (b,c,d) Diaphyseal fracturesmay be simplewedge complex.(e,f,g) Proximal and distal fractures may be extra-articular,partial articular complete articular.

How fractures are displaced

• Fractures can be displaced by:– Force of the injury– Effects of gravity– Pull of muscles attached to the site

Types of displacement

• Translation (shift)- the fragments may shift sideways, backwards or forwards

• Angulation (tilt)- mal alignment if unconnected will lead to limb deformity

• Rotation (twist)- rotational deformity • Length- can cause shortening of the bone

Mechanism of injury

• Injury• Repetitive stress• Pathological fractures

• INJURY

o Direct force- With a direct force, the bone breaks at the point of impact; the soft tissues also are damaged.

o Indirect force-the bone breaks at a distance from where the force is applied.

Some fracture patterns reveals the dominant mechanism:

Spiral pattern- twisting Oblique- compression Triangular- bending Transverse- tension

Some fracture patterns suggest the causal mechanism: (a) spiral pattern (twisting); (b) shortoblique pattern (compression); (c) triangular ‘butterfly’ fragment (bending) and (d) transverse pattern (tension). Spiral and some (long) oblique patterns are usually due to low-energy indirect injuries; bending and transverse patterns are caused byhigh-energy direct trauma.

• FATIGUE OR STRESS FRACTURES-

Occur in normal bone, subject to repeated heavy loading, typically in athletes, dancers or military personnel.

Drugs like steroids and methotrexate

• PATHOLOGICAL FRACTURES- Occurs in a bone that is made weak by some disease.

Causes- Inflammatory- OsteomyelitisNeoplastic- giant cell tumour, Ewings sarcoma, secondaries

Miscellaneous bone conditions- simple bone cyst, anuerysmal bone cyst

Heriditary- Osteogenesis imperfecta, Osteopetrosis

Other acquired generalised diseases- Osteoporosis, osteomalacia, rickets

BONE HEALING

• PRIMARY FRACTURE HEALINGrefers to fractures treated operatively withoutcallus formation

• SECONDARY FRACTURE HEALINGrefers to (a) fractures treated non-operatively, with the formation of callus and no disturbanceof hematoma; (b) fractures operated withoutdisturbance of hematoma

FACTORS AFFECTING BONE HEALING

(A)Age: Fractures unite faster in children(B)Type of bone: Faster union in flat and

cancellous bone(C) Pattern of fracture: Spiral # > oblique # >

transverse # > comminuted #(D)Disturbed pathoanatomy: soft tissue

interposition and ischaemic # prevent faster healing

(E)Type of reduction: good apposition of fracture results in faster healing(F)Immobilisation: depends on the fracture site eg. Fracture ribs and scapula do not require immobilisation(G)Open fractures: often go into delayed union and non-union(H)Compression of fracture site: enhances union(cancellous bone) and primary bone healing(cortical bone)

HEALING BY CALLUS• STAGE 1: TISSUE DESTRUCTION AND

HEMATOMA FORMATION- lasts for 7 days- blood leaks out of torn vessels and forms a hematoma between and around fracture- periosteum and local soft tissues are stripped off- ischaemic necrosis – death of some osteocytes with sensitization of the remaining precursor cells

• STAGE 2: INFLAMMATION AND CELLULAR PROLIFERATION/GRANULATION TISSUE

- lasts for 2-3 weeks- precursor cells form cells that differentiate and organize to provide q vessels, fibroblasts, osteoblasts etc- soft granulation tissue formed between fracture fragments, providing anchorage to fracture- hematoma is slowly absorbed and fine new capillaries grow into the area

• STAGE 3: CALLUS FORMATION- lasts for 4-12 weeks- granulation tissue differentiates and creates osteoblasts, laying down intercellular matrix impregnated with calcium salts- formation of callus/woven bone- provides good strength to the fracture, decreasing the movements at the fracture site and causes union in about 4 weeks

• STAGE 4: REMODELLING- takes 1-4 years for the bone to become strong enough to carry weight- with continuing osteoclastic and osteoblastic activities, the woven bone gets transformed into lamellar bone- osteoblasts fill in the remaining gap between the new bone and the fragments to strengthen the bone

• STAGE 5: MODELLING- stage where the bone is gradually strengthened- shapening of the cortices occurs at the endosteal and periosteal surfaces- all these occur when the person starts resuming his activities ie bearing weight and muscle forces- thicker lamellae are laid down where high stresses are present, unwanted buttresses are carved away and medullary cavity is reformed

HEALING BY DIRECT UNION

• Formation of callus requires stimulus from movement

• In cases of impacted fracture in cancellous bone or a fracture immobilised by the use of metal plate, callus will not be formed and hence the fracture will heal by direct union

1. Osteoblastic new bone formation occurs directly between the fracture fragments

2. New capillaries and osteoprogenitor cells grow in from the edges and lay down new bone on the exposed surface (gap healing)

3. Lamellar bone is produced in the narrow crevices (<200μm) while woven bone is produced in the wider gaps which is then remodelled into lamellar bone

4. Penetration and bridging of the fracture by osteoclasts and osteoblasts in 3-4 weeks.5. Intimacy of the contact surfaces lead to internal bridging without intermediate stages (contact healing)

CLINICAL PRESENTATION OF FRACTURES

In the Casualty..

• Take a Brief History.• General Particulars:

• AGE & SEX Children and the elderly Different mechanisms of injury : Traumatic , Pathological Post menopausal women : Osteoporosis and pathological fractures.

• HISTORY OF TRAUMA – Ascertaining the mechanism of injury is important, helps understand symptoms and aids examination.

SYMPTOMS

• A history of injury, followed by inability to use the injured limb.

The fracture may not always be at the site of the injury.• Eg : A blow to the knee and its varied effects. If a fracture occurs with trivial trauma, or spontaneously, suspect a

pathological lesion.

• Pain• Bruising • Swelling These are common symptoms but they do not distinguish a fracture from a soft-tissue

injury.

• Deformity – More suggestive of a fracture.• Enquire about symptoms of associated injuries:

Pain and swelling elsewhere (it is a common mistake to get distracted by the main injury, particularly if it is severe),

Numbness or Loss of movement. Skin pallor or cyanosis. Blood in the urine. Abdominal pain. Difficulty with breathing. Transient loss of consciousness.

• Ask about previous injuries, or any other musculoskeletal abnormality that might cause confusion when the x-ray is seen. Finally, a general medical history is important, in preparation for anaesthesia or operation.

GENERAL SIGNS

• First follow the ABCs: look for, and if necessary attend to,• Airway obstruction, • Breathing problems, • Circulatory problems • Cervical spine injury.• Secondary survey – Examine the main injury- ascertain

the type of fracture, classify, plan a management protocol and look out for complications.

• It will also be necessary to exclude other previously unsuspected injuries.

LOCAL SIGNS

• Familiar headings of clinical examination should always be considered,

• (or damage to arteries, nerves and ligaments may be overlooked.)

• A systematic approach is always helpful: Examine the most obviously injured part. Test for artery and nerve damage. Look for associated injuries in the region. Look for associated injuries in distant parts.

LOOK

• For Swelling, bruising and deformity• Examine whether the skin is intact• Note also the posture of the distal extremity and the colour of the skin.

FEEL

• The injured part is gently palpated for localized tenderness.• The common and characteristic associated injuries should also

be felt for, even if the patient does not complain of them.• Vascular and peripheral nerve abnormalities should be tested

for both before and after treatment.

MOVE

• Crepitus and abnormal movement may be present.• More important to ascertain if the patient can move the joints

distal to the injury.

X-RAY INVESTIGATION

• X-ray examination is mandatory. • Rule of twos:

Two views – A fracture or a dislocation may not be seen on a single x-ray film, and at least two views (anteroposterior and lateral) must be taken.

Two limbs – In children, the appearance of immature epiphyses may confuse the diagnosis of a fracture; x-rays of the uninjured limb are needed for comparison.

Two films of the same tibia: the fracture may be ‘invisible’ in oneview and perfectly plain in a view at right angles to that.

Two limbs: Sometimes the abnormality can be appreciated only by comparison with the normal side; in this casethere is a fracture of the lateral condyle on the left side

R L

Two joints – In the forearm or leg, one bone may be fractured and angulated. Angulation, however, is impossible unless the other bone is also broken, or a joint dislocated. The joints above and below the fracture must both be included on the x-ray films.

Two injuries – Severe force often causes injuries at more than one level. Eg: In fractures of the calcaneum or femur it is important to also x-ray the pelvis and spine.

Two occasions – Some fractures are notoriously difficult to detect soon after injury, but another x-ray examination a week or two later may show the lesion. Eg: Undisplaced fractures of the distal end of the clavicle, scaphoid, femoral neck and lateral malleolus, and also stress fractures and physeal injuries.

Two joints: The first x-ray (1) did not include the elbow.This was, in fact, a Monteggia fracture – the head of the radius is dislocated; (2) shows the dislocated radiohumeral joint.

More than one occasion: A fractured scaphoid may not be obvious on the day of injury, but clearly seen 2 weeks later.

SPECIAL IMAGING

• Computed tomography (CT) may be helpful in lesions of the spine or for complex joint fractures; help in accurate visualization of fractures in ‘difficult’ sites such as the calcaneum or acetabulum.

• Magnetic resonance imaging (MRI) may be the only way of showing whether a fractured vertebra is threatening to compress the spinal cord.

• Radioisotope scanning is helpful in diagnosing a suspected stress fracture or other undisplaced fractures.

FINAL DESCRIPTION• Diagnosing a fracture is not enough; the surgeon

should describe it with its properties:• Is it open or closed? • Which bone is broken, and where? • Has it involved a joint surface? • What is the shape of the break? • Is it stable or unstable? • Is it a high-energy or a low-energy injury?In short, the examiner must learn to recognize what has been aptly described as the ‘personality’ of the fracture.

Complications of Fracture

VISCERAL INJURIES

• Often occur in fractures around the trunk• Penetration of lung by rib fractures which

causes pneumothorax• Rupture of bladder or urethra in pelvic

fractures• Require emergency treatment

VASCULAR INJURY

Injury Vessel

First rib fracture Subcalvian

Shoulder dislocation Axillary

Humeral supracondylar fracture Brachial

Elbow dislocation Brachial

Pelvic fracture Presacral and internal iliac

Femoral supracondylar fracture Femoral

Knee dislocation Popliteal

Proximal tibial Popliteal or its branches

Clinical features

• Paraesthesia or numbness• Injured limb is cold and pale or slightly

cyanosed• Weak or absent pulse

Treament

• All bandages and splints should be remove• Fractures re-x-rayed and if artery is being

compressed prompt reduction is required• Circulation reassessed repeatedly over the

next half hour• If no improvement, vessels must be explored

by operation with pre or peroperative angiography

• Cut vessel can be sutured, or a segment may be replaced by a vein graft, if it is thrombosed, endarterectomy may restore blood flow

• If vessel repair is done, stable fixation is a must and fracture should be fixed internally

NERVE INJURY

Injury Nerve

Shoulder dislocation Axillary

Humeral shaft fracture Radial

Humeral supracondylar fracture Radial or median

Elbow medial condyle Ulnar

Moteggia fracture-dislocation Posterior-interosseous

Hip dislocation Sciatic

Knee dislocation peroneal

Closed nerve injuries

• Seldom severe and spontaneous recovery occurs in 90% within 4 months

• Nerve should be explored if no recovery, nerve conduction studies and EMG fail to show evidence of recovery

Open nerve injuries

• Nerve should be explored at the time of debridement and repair at the time or at wound closure

Acute nerve compression

• Sometimes occurs with # or dislocations around the wrist

• Numbness or paraesthesia in distribution of the median or ulnar nerves

• # reduction or splitting of bandages around the splint

• If no improvement within 48 hours, nerve should be explored and decompressed

• Indications for early exploration1. Associated with open #2. Fractures that need internal fixation3. Presence of concomitant vascular injury4. Diagnosed after manipulation of the #

HAEMARTHROSIS

• # involving joint• Joint is swollen, tense and patient resist any

attempt at moving at• Blood should be aspirated before dealing with

#

INFECTION

Early infection

• May present as wound inflammation without discharge

• Causal organism1. S. aureus2. Pseudomonas• Antibiotics may allow # to proceed to union as

long as fixation remains stable• But further surgery is likely later, when

antibiotics are stopped

Late presentation

• May present with a sinus and xray evidence of sequestra

• Implants and all avascular pieces of bone should be removed

• External fixator can be used to bridge the #• If resulting defect too large for bone grafting,

patient should be referred to a limb reconstruction centre

• When infection involves a joint, principles of treatment are the same as with bone infection, namely debridement and drainage, drugs and splintage

• On resolution of infection, # is stabilize so that joint movement can recommence

• If # cannot be stablized, joint should be splinted in the optimum position

• Can lead to permanent stiffness

Compartment Syndrome

• Occurs with fracture of elbow, forearm bones, proximal third of tibia, hands or foot ;

• Crush injuries and circumferential burns• Increase of pressure within the osseofascial

compartment• Due to bleeding , oedema or inflammation

• Clinical features– Pain : bursting sensation– Altered sensibility – Paresis / weakness in active muscle contraction– Testing the muscle by stretching them ( ischemic

muscle is highly sensitive to stretch and it causes pain )

• Confirmation of diagnosis–Measuring the intracompartmental pressures• Introduced a split catheter into the

compartment• Pressure measured close to level of the fracture• Differential pressure (difference between the

diastolic pressure and compartment pressure ) is <30mmHg – immediate decompression

• Management– Remove any casts, bandages and dressings– Differential pressure < 30mmHg – immediate

fasciotomy

Gas gangrene

• Produced by Clostridial infection• Present in dirty wound with dead muscle that

are closed without adequate debridement• Toxins can cause necrosis of tissue and

promote the spread of the disease

• Clinical features – Within 24 hours of injury– Intense pain – swelling around the wound– Brownish discharge– Little or no pyrexia– Increase pulse rate– Characteristic smell– Patient rapidly become toxemia and may lapse

into coma and death

• Prevention– All dead tissue should be completely excised– Doubt about tissue viability – wound should be

left open

• Treatment – Early diagnosis– Fluid replacement & IV antibiotics– Hyperbaric O2 – limit the spread of gangrene– Prompt decompression of the wound and removal

of dead tissue– Amputation in advance cases

Fracture Blisters• 2 types – Clear fluid filled vesicles– Blood stained

• Occur during limb swelling• Due to elevation of the epidermal layer of the

skin from the dermis• No advantage in puncturing the blister ( cause

local infection )• Surgical incision can be done after the limb

swelling decrease

Plaster and Pressure Sores

• Occur where the skin presses directly onto bone

• Traction on a Thomas Splint ( wrong ring size, excessive fixed traction and neglect)

• Prevention– Padding the bony points – Moulding the wet plaster so that pressure is

distributed to the soft tissue around the bony points

• Treatment– Patient feels the localised burning pain ( warning

sign )– Window must be immediately cut in the plaster– If unnoticed, skin necrosis will progress

LATE COMPLICATIONS

DELAYED UNION

When a fracture takes more than usual time to unite, it is said to have gone in ‘delayed union’.

Causes

Factors causing delayed union can be summarized as:biological, biomechanical or patient-related.

BIOLOGICAL--Inadequate blood supply--Severe soft tissue damage affects fracture healing by: (1) reducing the effectiveness of muscle splintage(2) damaging the local blood supply and (3) diminishing or eliminating the osteogenic input from mesenchymal stem cells within muscle--Periosteal stripping

BIOMECHANICAL--Imperfect splintage--Over-rigid fixation--Infection

PATIENT RELATEDIn a less than ideal world, there are patients who are:• Immense• Immoderate• Immovable• Impossible.These factors must be accommodated in an appropriatefashion.

Clinical features

-Fracture tenderness persists -Pain may be acute-On x-ray- fracture line remains visible - there is very little or incomplete callus

formation or periosteal reaction - However, the bone ends are not sclerosed or atrophic (suggest that,

although the fracture has not united, it eventually will)

Treatment

Conservative principles are: (1) to eliminate any possible cause of delayed union (2) to promote healing by providing the most appropriate environment

Immobilization (whether by cast or by internal fixation) should be sufficient to prevent shear at the fracture site, but fracture loading is an important stimulus to union and can be enhanced by: (1) encouraging muscular exercise (2) by weightbearing in the cast or brace

OPERATIVE

--If union is delayed for more than 6 months and there is no sign of callus formation, internal fixation and bonegrafting are indicated.

NON-UNION

Delayed union gradually turns into non-union – that is it becomes apparent that the fracture will never unite without intervention

Movement can be elicited at the fracture site and paindiminishes; the fracture gap becomes a type of pseudoarthrosis.

This patient has anobvious pseudarthrosisof the humerus.

The X-ray shows a typical hypertrophic non union

X-ray -The fracture is clearly visible but the bone on either side of it may show either exuberant callus or atrophy

-This contrasting appearance has led to nonunion being divided into hypertrophic and atrophic types.

-In hypertrophic non-union the bone ends are enlarged, suggesting that osteogenesis is still active but not quite capable of bridging the gap

-In atrophic non-union, osteogenesis seems to have ceased

Causes

Biological and patient related:(1) poor soft tissues (from either the injury or surgery)

(2)local infection

(3) associated drug abuse, anti-inflammatory or cytotoxic immunosuppressant medication

(4) non-compliance on the part of the patient.

TREATMENT

CONSERVATIVE

Non-union is occasionally symptomless, needing no treatment or, at most, a removable splint with hypertrophic non-union, functional bracing may be sufficient to induce union, but splintage often needs to be prolonged.

Pulsed electromagnetic fields and low-frequency, pulsed ultrasound canalso be used to stimulate union.

OPERATIVE

--hypertrophic non-union -- very rigid fixation alone (internal or external) may lead to union. --atrophic non-union, fixation alone is not enough. Fibrous tissue in the fracture gap, as well as the hard, sclerotic bone ends is excised and bone grafts are packed around the fracture. If there is significant ‘die-back’, this will require more extensive excision and the gap is then dealt with by bone advancement using the Ilizarov technique.

Malunion

• the fragments join in an unsatisfactory position (unacceptable angulation, rotation or shortening)

• Causes are : failure to reduce a fracture adequatelyfailure to hold reduction while healing proceedsgradual collapse of comminuted or osteoporotic

bone.

• Common sites: fractures at the ends of a bone• E.g. supracondylar fracture of the humerus,

Colles fracture.• Consequences:DeformityShortening of the limbLimitation of movements

• X-rays are essential to check the position of the fracture while it is uniting.

• Important during the first 3 weeks, when the situation may change without warning.

• Treatment1. In adults, • fractures should be reduced as near to the

anatomical position as possible. • Angulation of more than 10–15 degrees in a

long bone or a noticeable rotational deformity may need correction by remanipulation, or by osteotomy and fixation.

2. In children, • angular deformities near the bone ends (and

especially if the deformity is in the same plane as that of movement of the nearby joint) will usually remodel with time;

• rotational deformities will not.

3. In the lower limb, • shortening of more than 2.0 cm is seldom

acceptable to the patient • a limb length equalizing procedure may be

indicated.

Avascular Necrosis

• Certain regions are notorious for their propensity to develop ischaemia and bone necrosis after injury

• Common sites:the head of the femur (after fracture of the femoral

neck or dislocation of the hip)the proximal part of the scaphoid (after fracture

through its waist)the lunate (following dislocation)the body of the talus (after fracture of its neck).

• ConsequencesDeformation of the boneLeads to secondary osteoarthritis a few years

laterPainful limitation of joint movement

• X-ray shows the characteristic increase in x-ray density, which occurs as a consequence of two factors:

• Disuse osteoporosis in the surrounding parts gives the impression of ‘increased density’ in the necrotic segment,

• and collapse of trabeculae compacts the bone and increases its density.

• Treatment :usually becomes necessary when joint function is

threatened. In old people with necrosis of the femoral head an

arthroplasty is the obvious choice; in younger people, realignment osteotomy (or, in

some cases, arthrodesis) may be wiser. Avascular necrosis in the scaphoid or talus may

need no more than symptomatic treatment, but arthrodesis of the wrist or ankle is sometimes needed.

Growth Disturbance

• In childern, due to damage to physis• Transverse fractures not dangerous as long it

does run through germinal zone• Prevented by accurate reduction• Epiphysis splitting fractures -> asymmetrical

growth and angulated bone ends• Complete cessation of growth – if entire physis

is damaged.

Bed Sores• Elderly or Paralysed • Skin over sacrum and

heels – most vulnerable• Prevention by careful

nursing and early activity• Treatment is difficult. By

necrotic tissue excision and skin grafting

• Vacuum assisted closure for sacral sores

Myositis Ossificans

• Heterotopic ossification after injury

• Dislocation of elbow or blow to brachialis, deltoid or quadriceps

• Pain , swelling and tenderness

• Bone scan – increased activity• Limited joint movement• 8 weeks , easily palpable ,

defined in x ray• Immobilization, Excision,

NSAIDS ,Radiotherapy

Tendon Lesions

• Tendinitis – Tibialis posterior tendon after medial malleolar fractures

• Rupture of EPL tendon 6-12 weeks after fracture of lower radius

• Corrected by transfer of extensor indicis proprius tendon

Nerve Compression

• Lateral popliteal nerve – external rotation• Radial palsy – crutches• Numbness, paraesthesia, loss of power and

wasting• Ulnar, Median and Posterior tibial nerve• Decompression

Muscle Contracture

• Ischaemic contractures of affected muscles• Deformity and stiffness• Forearm and hand, leg and foot• Wasting and Clawing of fingers• Due to injuries and tight bandage• Calf ischemia – popliteal artery or its divisions• Tendon transfer

Joint Instability and Stiffness

• Instability – Ligamentous laxity, muscle weakness and bone loss

• Recurrent dislocation• Stiffness – knee, elbow ,shoulder ,small joints

of hand • Hemarthrosis – synovial adhesions• Treatment is by exercise to prevent occurence

Sudeck’s dystrophy

• Complex regional pain syndrome• Algodystrophy• Reflex sympathetic dystrophy• Type 1 – RSD develops after injurious or

noxious event• Type 2 – Causalgia develops after nerve injury• Pain(burning),swelling,redness,pale skin and

atrophy

• Early recognition• Elevation and active exercises• NSAIDS, regional anaesthesia• Drugs like amitriptyline, carbamazepine and

gabapentin• Physiotherapy

Osteoarthritis

• Damage to articular cartilage –post traumatic• Irregular joint surface – local stress• Intra – articular osteotomies and repositioning

of fragment• Malunion – secondary osteoarthritis